Maternal Aneurysmal Subarachnoid Hemorrhage During Pregnancy as an Interdisciplinary Task

Abstract

Maternal aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy presents a challenge regarding treatment and management. Due to the limited number of cases there are no treatment guidelines available. Thus, treatment is usually done on a case-by-case basis. Here we report on four cases of aSAH during pregnancy, describing the different management strategies and suggesting a possible treatment algorithm. Patients treated between 2003 and 2013 in our center were included in this retrospective study. Clinical data focused on time management concerning gestation week (GW), microsurgical or endovascular treatment, and outcome of the patients and the fetuses. Results were compared to the present literature on this issue. Mean age was 30.8 years, initial Hunt & Hess (H&H) grade ranged from III to V. All patients suffered from aSAH during the 3rd trimester of pregnancy. In the four cases, two emergency Caesarean sections (CS) were performed. Two aneurysms were occluded by microsurgical clipping and one was treated endovascularly. One patient died before definitive treatment of the aneurysm could be achieved, whereas fetal mortality was 0%. The mean follow-up was 83 months. aSAH during pregnancy needs individualized interdisciplinary management. Efforts must focus on the mother so that a delay in the best available treatment for the pregnant patient is avoided. Therefore treatment modality should be primarily determined by the aneurysm itself. However, timing in terms of delivery of the fetus and aneurysm treatment is a crucial point.

Subarachnoid haemorrhage in pregnancy after in vitro fertilisation with egg donation: a case report and review of the literature

“…Some studies, however, have found no increased incidence of SAH in pregnancy, and there is paucity of data regarding the potential risk conveyed by either twin pregnancy or IVF procedures. 5 To our knowledge, this is the first case reported of a SAH in a woman with history of IVF conception. She had the well-established risk factors for SAH of a right MCA aneurysm, hypertension and a high BMI.…”

“…Some groups have suggested a therapeutic algorithm to simplify the management of SAH in pregnancy which considers the gestation, radiation exposure and location of an aneurysm to advise treatment and timing of delivery. 5 Further work, however, is required to develop recommendations for the standardised management of CVA in pregnant women and in particular those undergoing IVF. 19…”

“…Some studies, however, have found no increased incidence of SAH in pregnancy, and there is paucity of data regarding the potential risk conveyed by either twin pregnancy or IVF procedures. 5…”

“…4 Whether the incidence of aneurysmal SAH is higher in pregnant women, however, is contested. 5 In the United Kingdom, for example, SAH has been reported to occur in 8-31 per 100,000 pregnancies and risk is highest in the third trimester. This is likely due to the haemodynamic and hormonal changes occurring with advancing gestation, such as increasing blood pressure and the level of circulating oestrogen.…”